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Physicians are being asked by local, state and federal agencies to do more to maintain their licensure and medical staff credentials in order to demonstrate their commitment to lifelong learning. In general, the requirements to practice our profession are increasing. These additional demands may seem overwhelming and, at times, unacceptable. On the other hand, our patients deserve physicians who can deliver the most appropriate evidence-based care and document the quality of their practice. Maintenance of Certification in Anesthesiology (MOCA®) consists of four parts, with the fourth being Practice Performance Assessment and Improvement (PPAI). One requirement of MOCA® Part 4 is participation in a PPAI activity at an endorsed simulation center, and recently many anesthesiologists are asking whether meaningful practice improvement is occurring as a result of this simulation requirement.